Cost-cutting measures fueled SARS spread

Just 16 months before SARS hit Toronto, the Ontario government deemed the last of its leading lab scientists redundant and sent them packing as it scoffed at the prospect of any new disease threatening the province.

The timing of government layoffs on Oct. 18, 2001, left five top microbiologists in utter disbelief. Walkerton's tainted-water scandal was a fresh memory. Bioterror threats loomed after Sept. 11 and the West Nile virus had made its Ontario debut.

But the Ontario government declared at the time that the province no longer needed their scientific expertise, insisting there were no new tests to develop: "Do we want five people sitting around waiting for work to arrive?" said Gordon Haugh, a Health Ministry spokesman. "It would be highly unlikely that we would find a new organism in Ontario."

The SARS virus made a mockery of government predictions and exposed the weaknesses of a stripped-down public-health system that many had warned was headed for crisis, a Globe and Mail investigation has found.

"SARS was an accident waiting to happen — because of the priorities of the government, the cost-cutting measures, the conditions were great for SARS to take hold," said William Bowie, an infectious disease specialist at the University of British Columbia who answered Toronto's cry for help during the early weeks of the outbreak of severe acute respiratory syndrome.

People on the front lines fighting SARS say it is nothing short of a miracle that a "bare-bones" public-health system managed to control the crisis.

It was done despite skimpy resources and with the help of a fractured crisis-management crew that relied on favours, volunteers and "begging and borrowing" everything from software to scientists.

The outbreak highlighted the dire shortage of health workers to trace those at risk of the disease and glaring shortcomings in the province's laboratory services.

It exposed a patchwork communication system that left the containment team no direct means of quickly contacting hospital workers. And with no established, central body of infectious-disease experts in Ontario, officials had to cobble together a last-minute team to track crucial details about the disease, including incubation time and how it was being transmitted.

For years, infectious-disease experts have warned that a flu pandemic is looming and that Ontario needed to bolster its support of public health.

"It's been very clear to us that we were going to pay for the public-health dismantling that has happened under the provincial and municipal governments," said Allison McGeer, head of infection control at Toronto's Mount Sinai Hospital and one of the key members of the SARS containment team.

Ontario's understaffed lab, which sits in Toronto's west end on the ironically named Resources Road, is just one example of the inadequacies.

It was once considered a world-class reference laboratory, with dozens of top-notch scientists who watched for coming infections and anticipated new disease threats by designing diagnostic tests to detect them. But by 2003, according to one of those laid off, "there was no one left watching any more."

Among those let go in 2001 was microbiologist Ching Lo, who was designing a test for the West Nile and Norwalk viruses, and Martin Preston, who was developing a rapid-detection method for the E-coli bacteria responsible for the Walkerton outbreak.

"We're living in the richest province in Canada and we couldn't afford to have a top-notch public-health lab system to support outbreaks," Dr. Preston said.

Even before the layoffs, a steady stream of scientists had left the lab, frustrated by cost cuts. None was replaced. Today two microbiologists remain. "I saw the public-health labs and the public-health units being underfunded and under-supported and being dismantled from the inside out. I didn't want to be part of that," said Neal denHollander, who headed the provincial lab's standards and development section until 2001.

By the time of the SARS outbreak, lab scientists at the Hospital for Sick Children had decided to band together with colleagues at other hospitals and the provincial lab to do the work that Ontario's public lab used to perform alone.

Susan Richardson, head of microbiology at Sick Kids, said her colleague Raymond Tellier decided on his own to develop a diagnostic test for the coronavirus behind SARS.

"The ability to respond to this outbreak came from the efforts of individuals," said Dr. Richardson. "[Dr. Tellier] in a hospital lab used his own initiative to work day and night and weekends to develop this test. Efforts such as these, she explained, are "the only reason we have survived this outbreak against all odds."

The Sick Kids' work led Dr. Richardson to spearhead the creation of the "Ontario Laboratory Working Group for the Rapid Diagnosis of Emerging Infections." Last month, Ontario pledged $2.5-million for its research on a SARS test.

Dr. denHollander, who now heads the regional lab in Toronto that runs tissue-compatibility tests for transplants, applauded the hospital labs. But, he said, "It's filling a void that ought not to exist, that hospitals are doing this speaks largely to the abdication of responsibility here."

** Early in the outbreak, Donald Low, chief microbiologist of Toronto's Mount Sinai Hospital and a key member of the containment team, recognized quickly that officials needed experts who could study the big picture

Such a resource was readily available at the B.C. Centre for Disease Control, where microbiologists and disease trackers — including Ontario's former chief epidemiologist — work.

But Ontario has no such central body, and Dr. Low found himself lobbying James Young, commissioner of public security, to recruit the staff. Dr. Young gave the go-ahead on March 29, as the SARS caseload skyrocketed, and Dr. Low recruited colleagues from Halifax, Ottawa, Kingston and B.C. to form a scientific advisory group, promising to pay their expenses.

The willingness of people to volunteer compensated for gaps in the system, said Dr. McGeer; "people like Dick Zoutman, who chaired the SARS scientific advisory committee . . . dropped everything he was doing to help."

Some of those who came from other parts of the country were struck by the ramshackle state of the public-health infrastructure in Canada's most populous province.

"I saw a lot of people working really, really hard to try and deal with each new onslaught, and at the same time try to create some kind of a co-ordinated management structure that didn't exist," Dr. Bowie said.

But infection control was not the only weakness. The ministry seconded University of Toronto epidemiologist Ian Johnson.

But Dr. Johnson needed a team to collect and analyze the data from the dozen Ontario public-health units reporting SARS cases. So out went another call for volunteers, bringing in workers from as far away as Winnipeg.

"We needed a centralized agency within the province to handle this sort of thing. We needed somebody in charge who had the authority to make decisions and the resources to do what had to be done to carry them out," Dr. Low said.

"Instead we were borrowing and begging to carry out a proper investigation." Dr. Johnson, a mild-mannered scientist given to backpacks and corduroys, began work on April 1, building a computerized database with software Health Canada had passed on.

"The main challenge for me was that each of the health units already had their systems in place for three weeks, and they were going flat out," Dr. Johnson explained. He had to create a standard SARS case report form and a system for each public-health unit to call the ministry daily with information on each new patient.

Without this collated data, Dr. Low explained, all that existed were fragments of information that did not allow recognition of trends.

It was Dr. Johnson and his epidemiological team that gathered enought patient data to be sure the maximum incubation period for SARS was 10 days.

"The average was four to five days," said Dr. Johnson. "But knowing the maximum period was important for planning quarantine times."

It turned out to be a major stroke of luck for the containment team. Even before Dr. Johnson arrived, health officials had recommended 10-day quarantine periods.

This, said Dr. Bowie, was based on the Hong Kong experience and "a whole lot of finger-crossing."

Dr. Bowie was dismayed to learn when he got to Toronto that an epidemiology team was not in place. "In a more desirable world, that would have already existed," Dr. Bowie said. "But they had to start from scratch."

He was not entirely surprised. For years, he has attended planning meetings for the predicted flu pandemic with colleagues from other provinces, and marvelled at Ontario's shortcomings.

"Ontario does not seem able to pull together an integrated effort, either for pandemic planning or to deal with bioterrorism," he said. "It's gotten progressively worse. Advice has been ignored for a long time."

At the local level, Sheila Basrur's health unit was forced to pull staff away from investigations of syphillis cases and an outbreak of tuberculosis in Toronto's hostels to work on SARS.

"We would try to beg, borrow or steal staff from other health units who could voluntarily come to Toronto and help out for a week or two and then go back to their home base," Dr. Basrur said.

Twenty people were borrowed from other health units in the province, 62 were reassigned from other investigations, accounting for a total of 305 people in Toronto charged, among other things, with tracing the movements of thousands of people.

"It's like ripping the bandage off of one wound to stop the bleeding of another one," Dr. Basrur said.

** The lack of a central communication system haunted health officials on the front line.

For years, Dr. McGeer, Dr. Low and their colleagues had lobbied for an electronic, province-wide database that would allow doctors to connect patient information with lab results or any epidemiological data.

"You have an electronic file and you might have a hand-written result, and so someone can access that file, but not know about the note, and so there is no connection made," Dr. Low said.

During the SARS outbreak, the rapid flow of information about suspect cases relied on telephone calls, faxes, and e-mails, all flooding in from hospitals and clinics to the public-health units.

Dr. Johnson has been compiling this data into a central data base, but only provincial ministry officials have access, he explained. In fact, in the seventh week of the outbreak, the province has still not decided whether it will allow health officials in Toronto and York to have access to the system that their information helped create.

Dr. Johnson said the issue is whether York officials should be allowed access to Toronto data, and vice versa — even though they routinely exchange such information by phone.

"You are trying to balance privacy issues with the speed of trying to respond to an outbreak," Dr. Johnson said.

Monika Naus, once Ontario's chief epidemiologist, and now the associate director of epidemiology services at the B.C. Centers for Disease Control, an arms-length provincial agency, said she too realized the need for a centralized system when she left Ontario in 2001.

"B.C. has much less stringent data-sharing information," she said. Meanwhile, communication lines between the containment team and the hospital staff also proved less than efficient.

Dr. Bowie noted that the scientific advisory body would draft policies for infection-control measures and pass them on to the executive SARS committee, which included Dr. Young and Ontario commissioner of public health, Colin D'Cunha.

"We never really knew if the directives were passed on, or if they weren't," Dr. Bowie said. Sometimes, the scientists would discover that the directives sent did not resemble those they had drafted.

The inefficient communications left some doctors wondering what they might have been able to prevent if they had known crucial details about how people were contracting SARS.

Dr. McGeer, for example, noted that early in the outbreak at Scarborough Grace Hospital, there had been infections associated with intubating a patient.

"Maybe if we had that data," she said, "we might have seen more clearly the risk involved in certain procedures and prevent what happened at Sunnybrook [where several health workers contracted SARs after a four-hour long effort to intubate a patient]."

** The Ontario government has pledged a full postmortem on the handling of the SARS outbreak. Dr. Bowie said this week from B.C. that he hopes to be included.

"SARS is a tragedy," he said. "But it would be a much worse tragedy for Canadians not to learn from the lessons we can take from this."

Ontario Health Minister Tony Clement, widely lauded for his leadership role in the outbreak, now appears to be fully supportive of boosting public health.

And Health Ministry spokesman John Letherby noted that Ontario has increased its spending on public-health labs to $62.6-million in 2002-2003 from $41.7-million the year before. That includes wages, cost of equipment, supplies and other items for Ontario's 37 public-health units, but not overall budgets, he said.

Yet, in the middle of a provincial emergency — declared for the first time in history for reasons of public health — Dr. Basrur wonders why this week's Throne Speech did not mention public health.

"I challenge you to find any mention of public health in there," she said. ". . . We're in the middle of a wake-up call and people are still sleeping."

For a ferocious indictment of the socialist Canadian health care system to SARS, written by one helluva eloquent Canuck dude:

Mark Steyn in the National Post: The system infected us

One of the most tediously over-venerated bits of British political wisdom is Prime Minister Harold MacMillan's amused Edwardian response as to what he feared most in the months ahead: "Events, dear boy, events."

But even events come, so to speak, politically predetermined. If, for example, you have powerful public sector unions, you will be at the mercy of potentially crippling strikes. The quasi-Eastern European Britain of the 1970s was brought to a halt by a miners' strike in a way that would have been impossible in the United States.

So it is with SARS. The appearance of the virus itself was a surprise but everything since has been, to some extent, predictable. Because totalitarian regimes lie, China denied there was any problem for three months, and thereafter downplayed the extent of it. Because UN agencies are unduly deferential to dictatorships, the World Health Organization accepted Beijing's lies. This enabled SARS to wiggle free of China's borders before anyone knew about it. I mentioned all this three weeks ago, but only in the last couple of days has the People's Republic decided to come clean -- or, at any rate, marginally less unclean -- about what's going on.

As for our diseased Dominion, like the Chinese our leaders behaved true to form. When something bad happens in Canada, the priority is to demonstrate how nice we are. After September 11th, the Prime Minister visited a mosque. After SARS hit, the Prime Minister visited a Chinese restaurant. Insofar as one can tell, Chinese Canadians seem to be avoiding Chinese restaurants at a somewhat higher rate than caucasians. But, while it may have been blindsided by the actual outbreak of disease, the Canadian system is superb at dealing with entirely mythical outbreaks of racism. I think we can take it as read that if a truck of goulash exploded on the 401 killing 120, the Prime Minister would be Hungarian folk dancing within 48 hours. Personally, I'd have been more impressed if he and Aline had had a candlelit dinner for two over a gurney in the emergency room of a Toronto hospital. That's the issue -- not Canadian restaurants, but Canadian health care.

But the piped CanCon mood music has wafted over Jean and Aline's table and drowned out the more awkward questions. Toronto is the only SARS "hot zone" outside Asia. Of nearly 200 nations on the face of this Earth, Canada is one of only eight where SARS has killed, and currently ranks third, after China and Singapore, in the number of SARS deaths. Indeed, Canada had the highest SARS fatality rate in the world until one of two infected Filipinos died a few days ago -- and according to its government she picked it up from the mother of her Toronto roommate. But why get hung up on details? "Over the past six weeks, health care workers across Toronto have done an amazing job," wrote Joseph Mapa, president of Mount Sinai Hospital, on our letters page yesterday. "We need to applaud these men and women for their dedication and commitment."

No, we don't. We can indulge in lame-o maple boosterism if we ever lick this thing. Until then, we need to ask: Why Toronto? London, Sydney, San Francisco and other Western cities have large, mobile Asian populations. But they don't have SARS. The excuse being made for China is that they have vast rural provinces with limited access to health care. So what's Toronto's? Here's the timeline:

February 11th: The WHO issued its first SARS health alert, which was picked up by the American ProMed network, which distributed it to Toronto health authorities. The original alert has been described as "obviously significant" by those who saw it.

February 28th: Kwan Sui-Chu, having recently returned from Hong Kong, goes to her doctor in Scarborough complaining of fever, coughing, muscle tenderness, all the symptoms of the by now several ProMed alerts. As is traditional in Canada, the patient is prescribed an antibiotic and sent home.

March 5th: Having apparently never returned for further medical treatment and slipped into a coma at home, Kwan Sui-Chu is found dead in her bed. The coroner, Dr. Mark Shaffer, lists cause of death as "heart attack." Later that day, Kwan's son, Tse Chi Kwai, visits the doctor, complaining of fever, coughing, etc. He too is prescribed an antibiotic and sent home. Later still, the son takes his wife to the doctor. Likewise.

March 7th: Tse Chi Kwai goes to Scarborough Grace, and is left on a gurney in Emergency for 12 hours exposed to hundreds of people.

March 9th: Scarborough Grace discovers Tse's mother has recently died after returning from Hong Kong. But Dr. Sandy Finkelstein concludes, if Tse is infectious, it's TB.

March 13th: Tse dies, and Scarborough Grace calls Dr. Allison McGeer, Mount Sinai's infectious disease specialist, who finally makes the SARS connection.

March 16th: Joe Pollack, who lay next to Tse on that Scarborough Grace ER gurney for hour after hour, returns to the hospital with SARS. He's isolated, but not his wife. Later that day, while at the hospital, Mrs. Pollack comes in contact with another patient who's a member of a Catholic Charismatic group.

March 28th: At a meeting of the Charismatic group, the ailing Scarborough patient's unknowingly infected son exposed 500 others to SARS ...

Let's leave it there. If this is what the President of Mount Sinai calls an "amazing job," then we might as well head for the hills screaming "We're all gonna die!" Toronto health authorities have done an amazing job that's amazing only in its comprehensive lousiness. At every link in the chain, anything that could go wrong did go wrong.

In rural China, SARS got its start through the population's close contact with farm animals. In Hong Kong, it was spread by casual contact in the lobby, elevators and other public areas of the Metropole Hotel. Only in Canada does the virus owe its grip on the population to the active co-operation of the medical profession. In Toronto, the system that's supposed to protect us from infection instead infected us. They breached the most basic medical principle: first do no harm. Even after they knew it was SARS, Scarborough Grace kept making things worse.

Dr. Mapa's pathetic attempts at covering his profession's ass are understandable. But most people who've had experience of Canadian health care will recognize the SARS chain as an extreme version of what usually happens. The other day, a guy I know went to a Quebec emergency room, waited for six hours, was told he had a migraine, and sent home. It turned out to be a life-threatening parasite in the brain. I'm sure you've got friends and family with similar stories. A chronically harassed, understaffed, underequipped system reaches reflexively for routine diagnoses, prescriptions. Did Kwan Sui-Chu's doctor, an Asian Canadian herself with many Asian patients, get the Toronto Public Health alert? Is it normal for coroners to mark "heart attack" as cause of death for elderly patients even when they've been prescribed antibiotics for a new condition in the last week? Why, after Scarborough admitted Mr. Pollack, whom they knew to have been infected during his previous stay with them, did they allow Mrs. Pollack to circulate among other patients? Why did Scarborough compound its own carelessness by infecting York Central?

Most of what went wrong could have been discovered by a few social pleasantries: How's the family? Been travelling recently? The so-called "bedside manner" isn't just to cheer you up, it's meant to provide the doctor with information that will assist his diagnosis. In Canadian health care, coiled tight as a spring, there's no room for chit-chat: give her the antibiotics, put it down as a heart attack, stick him on a gurney in the corridor for a couple of days. Maybe you could get service as bad as this in, oh, a Congolese hospital. But in most other Western health care systems the things Ontario failed to do would be taken for granted. There might be a lapse at some point in the chain but not a 100% systemic failure all the way down the line.

You'll notice that just like Red China, the Prime Minister and Toronto's medical staff I've reacted reflexively, blaming it in my right-wing way on the decrepitude of socialized health care, which almost by definition is reactive rather than anticipatory, and belatedly so at that. But my analysis, unlike Dr. Mapa's, fits the facts. But not to worry: as our leader is happy to assure us, our no-tier health care "express da Canadian value."

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